Will you be running an ambulance service soon? Pre-hospital care's role expands

Providers eye integration of EMS and hospitals as one cost-saving option to ED care

What's the next step in the consolidation of emergency health care services? Before long, your hospital's emergency department (ED) may extend well beyond the walls of the institution. Quite possibly, as medical director, you may end up in charge of a fleet of ambulances and paramedics in addition to your regular responsibilities of running an ED. Your additional duties will focus on redirecting patients away from the ED to lower levels of non-emergency medical care before the patient reaches your hospital.

Meanwhile, your facility or medical group could be charged with bundling the portion of the patient's medical claim stemming from the ambulance transportation into whatever medical care is ultimately rendered, either by the ED or an affiliated urgent care center or medical practice.

That, at least in theory, is the vision held by a growing number of health care professionals who believe the role played by ambulance providers in managed care has been sorely overlooked and understated-until now.

The idea behind integrating pre-hospital emergency medical services (EMS) with conventional hospital or physician-based functions is to better manage patients, cut down on unwarranted ED visits, and improve clinical outcomes through appropriate levels of medical care. A successful effort may be years away primarily due to a lack of data and clinical algorithms that can support a centralized package of service options with traditional ambulance providers playing a key role.

Capitation could spur integration of ambulance and hospitals

"The idea has been tossed around for years and makes a lot of sense. But there just isn't enough supporting data or interest by key players out there to justify the effort," says Michael Callaham, MD, chief of emergency medicine at UCSF Stanford Healthcare San Francisco (CA) Medical Center.

But the arrangement holds such strong promise for holding down costs and improving efficiencies that it may become a reality sooner than later, says Callaham. Here's why:

    · Capitation

The growing prominence of shared-risk capitation in many managed care markets has stirred discussions of expanding the role of ambulance providers.

    · Fraud and abuse probes

Another factor fueling interest in integration has been the growing concern by officials at government programs such as Medicare over widespread fraud and abuse in the billing for ambulance transportation. By expanding their scope of services, ambulance firms believe they can justify payment rates from Medicare and other payers and lift the specter of false or illegal billing that dogs them, some observers say.

    · Declining business

At the same time, ambulance providers are feeling the pinch of funding cutbacks on the public sector side and falling revenue in some markets due to competition among commercial providers. "Ambulance companies are trying to redefine themselves in ways that will make them more viable and cost-effective," says Keith W. Neely MPA, assistant professor of emergency medicine at Oregon Health Sciences University in Portland.

In an effort to stave off financial problems, EMS firms are consolidating. Some are going public and directly contracting with large, provider-driven managed care organizations to increase business.

    · Managed care

It has forced providers to forge new partnerships by trimming payments and demanding justification in medical necessity, Neely says. As an alternative, ambulance providers are finding new financial incentives in forming alliances with hospitals, physicians, and managed care organizations.

As envisioned, the process would involve using a central telephone triage nurse or physician who would direct the ambulance driver to an appropriate destination based on information supplied at the time of pick-up. The system would largely function in the same way as paramedics who transport critically ill or injured patients after accidents.

But these cases would involve a wider choice of clinical options and would require a much broader set of clinical information needed by the telephone triage individual, according to Callaham. "That's where the system has failed. We just don't have enough sophisticated knowledge to supply to individuals in the form of set, reliable algorithms," Callaham says. "How do we justify the triage nurse's decisions? Do we wing it?"

Efforts to launch integrated plans have failed

Recent efforts to create just such an integrated arrangement collapsed in California. California Emergency Physicians Medical Group in Oakland failed to create its own integrated pre-hospital triage and transportation system.

Talks broke down when participants couldn't reach agreement on details of the plan. However, at least one observer indicated the plans failed due to a lack of assurances that the system could in fact work and demonstrate why. "Again, there wasn't enough data to support any of the expected claims for effectiveness in these endeavors," Callaham surmises.

Meanwhile, Kaiser Permanente Medical Foundation in Oakland has been developing a standardized contract for all EMS and non-EMS patient transportation. The contract would essentially be risk-based on a shared capitated model with the provider, which would force the ambulance companies to share in the financial risk of rendering patient services, Neely says.

The Kaiser plan has yet to prove its efficiencies. But it comes closest of any efforts presently underway to integrate pre-hospital EMS with hospital or physician-based levels of care, Neely adds.

In a study published last year, Neely and co-authors predicted an expanding role for EMS from what is now a single-option resource for patients to a multi-option model based on the use of carefully designed clinical pathways to guide patients from point to point within several alternatives for medical care.1

But the authors admit that any such system would have to meet regulatory approval. And, according to Callaham, most cities and counties, including fire department governmental districts, "lack a research-based tradition" to enable them to justify such dramatic restructuring of the system.

But what keeps providers interested in the scheme? The opportunity to better manage patient outcomes while streamlining the acute care system offers considerable incentives, according to Callaham. "With a system like this, we could eliminate more than half of all unnecessary EMS calls. That's incentive enough," Callaham says.


    1. Neely KW, Drake MER, Moorhead JC, et al. Multiple options and unique pathways: A new direction for EMS? Ann Emerg Med 1997;30:797-799.